Unless someone is completely media averse, Walgreen’s decision to treat chronic diseases in their Take Care Clinics should not come as news. Patients rarely ask me how I feel about going to Immediate Care Centers or the “Quickie Mart” versions in retail pharmacies and grocery stores. Unfortunately as primary care physicians became harder to see at convenient hours, people went to physician-staffed Urgent Care Centers on the weekends and evenings originally. Then retail centers staffed by physician assistants and nurse practitioners opened for simple acute problems. Now Walgreens plans to care for patients’ chronic conditions, like hypertension, diabetes and asthma. They announced this as a way to “bridge the gap in patient care” and “improve care coordination”. Given that I have never received records on a patient treated in one of their Take Care Clinic, it makes me a bit skeptical of the latter.

Do I think this is optimal care? No. I’ve worked with many excellent nurse practitioners, one, in fact, who was better than many doctors. But she knew her limits and I worry that the staffing at these clinics will not have individuals of her caliber and experience in them. Will this worsen the fragmentation of medicine, a fragmentation that is exacerbating medical errors in an outrageous way? Yes. But I recognize that money and demand will out-trump best care most of the time. And I agree with Dr. Pho’s assessment that we brought this on ourselves(1).

My hope is that my patients will continue to seek care from me first. In turn I will try to develop other options to make myself more available. Presently I encourage patients to use my patient portal and soon, I hope to convince my employer to consider telemedicine capability.

A few months ago my office manager, Debbie, informed me that it was time for my annual “coding audit”. This is where my employer sends in a hired gun to determine if my choices of office codes for billing purposes are correctly done. Did I document enough to support a 99214? Did I code too many 99212s when my documentation should have been higher, and thus my reimbursement better? The audit is based on Medicare-guidelines, although the ten charts pulled were of patients of all ages and insurance types. Doctors generally approach these sessions with the same dread we felt getting our report cards in grade school.

The tiny blond that came in to discuss my results refused to sit down next to me. It was distracting and intimidating. Since I’m 5’10” it was also infuriating to have this schoolmarm personality towering over me while she explained why she’d flunked me. Seven out of ten charts did not pass her muster. Two of the explanations made sense – one was “overcoded” – not enough documentation to support the 99213 I’d coded and the other the opposite. Six charts were “complete physical exams” (CPE) done on healthy non-Medicare patients. Since Medicare does not pay for preventive exams why were they pulled for a Medicare audit? It got stranger. She told me that I’d flunked because there was no “chief complaint” on the physical form. What? There shouldn’t BE a chief complaint for someone who is having a physical. In fact, by definition, there shouldn’t be one because it is a preventive service. No amount of discussion would dissuade the woman that she was wrong. I didn’t have immediate access to my own specialty society’s information on the subject:

The comprehensive history and examination performed during a preventive medicine encounter are not the same as the comprehensive history and exam that are required for certain problem-oriented E/M codes (99201-99350) and defined in Medicare’s Documentation Guidelines for Evaluation & Management Services. In fact, the documentation guidelines don’t apply to preventive medicine services. The history associated with preventive medicine services is not problem-oriented and does not involve a chief complaint or history of present illness.

I gave up arguing, signed the form under written protest and she left.

Here is the kicker–a week ago one of the people whose chart was audited called to tell us she received all her money back on her physical! She thought it was a mistake and was upset. She argued with Debbie and insisted that my office take back the money saying “But Dr. Nieder did all that work and spent the time with me.”

I am furious. This suggests to those six patients that I did something wrong. Ironically, this means my employer is out hundreds of dollars for work they paid me for and that should rightfully have been reimbursed. Jawdropping in it’s lunacy. Can anyone wonder why the concierge movement is such an attractive, viable alternative to this?

One of my irritations with fast track care, especially Kroger’s Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes. A few days ago a new version of “careless care” appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a “sinus” infection, despite the fact that each time she’d only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she’d not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger “Little Clinics” where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup.

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can’t fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients’ physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.